Witness Statement Template
This Witness Statement is made on [Date] by:
Full Name of Witness: [First Name Last Name]
Address: [Full Address]
Phone/Email: [Contact Information]
Occupation: [Job Title or N/A]
Relationship to Case/Parties: [Relationship or N/A]
1. Statement Purpose and Reference
Case/Incident Reference: [Case name/claim #/internal file #/other]
Statement Requested By: [Name/Organization/Department]
Recipients Authorized to Receive This Statement: [Names/Departments or N/A]
2. Event Details
Date of Incident: [MM/DD/YYYY]
Time: [Time or Approximate Time]
Location: [Address/mile marker/intersection/site area description]
Scene Markers: [Landmark/gate/lot/aisle/other]
3. Witness Identification
Witness Name: [Witness Name]
Best Contact Method: [Phone/Email]
Availability for Follow-Up: [Days/Times/Time Zone]
4. Statement of Facts (Hazard → Control → Failure → Exposure → Injury/Damage)
Hazard: [Condition or activity observed]
Control: [Barrier/PPE/signage/traffic control/other/unknown]
Failure: [What did not work or was missing, if observed]
Exposure: [Who/what was exposed and how, if observed]
Injury/Damage: [Observed injury or property damage/unknown]
Additional Chronology: [Chronological description of what I observed]
5. Supporting Evidence
Exhibit A: [Photographs/Video files and identifiers]
Exhibit B: [Police report/incident report/other]
Exhibit C: [Diagram/repair estimate/other]
Additional Exhibits: [List or N/A]
6. Declaration of Truth and Signatures
I, [Witness Name], declare that the facts stated in this witness statement are true to the best of my knowledge and belief.
I understand that making a false statement may result in penalties under applicable perjury laws.
Witness Signature: _______________________ Date: ___________
Printed Name: ___________________________
Received By (optional): __________________________ Date: ___________
Role/Title: ______________________________
Supervisor Review (optional): ______________________ Date: ___________
7. Corrective Actions Log (Module)
Complete the corrective actions log:
Action | Owner | Due Date | Status | Ticket/Link |
[Action item] | [Name/Role] | [MM/DD/YYYY] | [Open/In Progress/Closed] | [ID/Link] |
[Action item] | [Name/Role] | [MM/DD/YYYY] | [Open/In Progress/Closed] | [ID/Link] |
[Action item] | [Name/Role] | [MM/DD/YYYY] | [Open/In Progress/Closed] | [ID/Link] |
Action | Owner | Due Date | Status | Ticket/Link |
[Action item] | [Name/Role] | [MM/DD/YYYY] | [Open/In Progress/Closed] | [ID/Link] |
[Action item] | [Name/Role] | [MM/DD/YYYY] | [Open/In Progress/Closed] | [ID/Link] |
[Action item] | [Name/Role] | [MM/DD/YYYY] | [Open/In Progress/Closed] | [ID/Link] |
Action
Owner
Due Date
Status
Ticket/Link
[Action item]
[Name/Role]
[MM/DD/YYYY]
[Open/In Progress/Closed]
[ID/Link]
8. Vehicle/Traffic Addendum (Module)
Vehicle 1: [Year/Make/Model/Color] Plate: [Plate] VIN (last 6): [XXXXXX]
Vehicle 2: [Year/Make/Model/Color] Plate: [Plate] VIN (last 6): [XXXXXX]
Direction of Travel/Positioning: [Description]
Traffic Controls/Signals: [Signals/signs/lanes/other/unknown]
Police/Report Reference: [Agency/report #/other]
9. Multi-Employer/Contractor Chain (Module)
Site Controller/Owner: [Name or Unknown]
General Contractor (if any): [Name or N/A]
Subcontractor/Vendor (if any): [Name or N/A]
Equipment/Tool Ownership (if relevant): [Owner/lessor/unknown]
10. Remote/Outdoor Access (Module)
GPS Coordinates (if relevant): [Latitude/Longitude or N/A]
Access Route: [Nearest road/entrance/parking/access notes]
Cell Coverage: [Good/Fair/Poor/Unknown]
Closest Facility or Meeting Point: [Name/address or N/A]
Action | Owner | Due Date | Status | Ticket/Link |
[Action item] | [Name/Role] | [MM/DD/YYYY] | [Open/In Progress/Closed] | [ID/Link] |
[Action item] | [Name/Role] | [MM/DD/YYYY] | [Open/In Progress/Closed] | [ID/Link] |
[Action item] | [Name/Role] | [MM/DD/YYYY] | [Open/In Progress/Closed] | [ID/Link] |
